NUR 265 Emergency Questions and Answers Latest Update 2023/2024

NUR 265 PRACTICE QUESTIONS ANSWERS AND RATIONALES Shock 1. 16 mm Hg pulse pressure. The pulse pressure is the systolic BP minus the diastolic BP. 100 – 60 = 40 mm Hg pulse pressure in first BP reading 88 – 64 = 24 mm Hg pulse pressure in second reading 40 – 24 = 16 mm Hg pulse pressure narrowing. A narrowing or decreased pulse pressure is an earlier indicator of shock than a decrease in systolic blood pressure. TEST-TAKING HINT: If the test taker is not aware of how to obtain a pulse pressure, the only numbers provided in the stem are systolic and diastolic blood pressures. The test taker should do something with the numbers. Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Physiological Integrity, Reduction of Risk Potential: Cognitive Level – Analysis: Concept – Perfusion. 2. 1. There are many types of shock, but the one common intervention which should be done first in all types of shock is to establish an intravenous line with a large-bore catheter. The low blood pressure and cold, clammy skin indicate shock. 2. This blood pressure does not require dopamine; fluid resuscitation is first. 3. The client may need ABGs monitored, but this is not the first intervention. 4. An indwelling catheter may need to be inserted for accurate measurement of output, but it is not the first intervention. TEST-TAKING HINT: This question asks for the first intervention, which means all options may be appropriate interventions for the client, but only one should be implemented first. Remember: When the client is in distress, do not assess. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level – Synthesis: Concept – Perfusion. 3. 1. These vital signs are expected in a client with septic shock. 2. An elevated WBC count indicates an infection, which is the definition of sepsis. 3. The client must have a urinary output of at least 30 mL/hr, so 90 mL in the last four (4) hours indicates impaired renal perfusion, which is a sign of worsening shock 4. The client being thirsty is not an uncommon complaint for a client in septic shock. This warrants immediate intervention. TEST-TAKING HINT: The words “warrant immediate intervention” mean the nurse must do something, which frequently is notify the health-care provider. Any client in shock will have signs and symptoms requiring the nurse to intervene. In this question, the test taker must determine priority and which data require immediate intervention. Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Physiological Integrity, Reduction of Risk Potential: Cognitive Level – Analysis: Concept – Perfusion. 4. 1. The client’s diet is not priority when transcribing orders. 2. An IV antibiotic is the priority medication for the client with an infection, which is the definition of sepsis—a systemic bacterial infection of the blood. A new order for an IV antibiotic should be implemented within one (1) hour of receiving the order. 3. Diagnostic tests are important but not priority over intervening in a potentially life- threatening situation such as septic shock. 4. There is no indication this client has diabetes in the stem of the question, and glucose levels are not associated with signs/symptoms of septicemia. TEST-TAKING HINT: Remember, if the test taker can rule out two answers—options “1” and “4”—and cannot determine the right answer between options “2” and “3,” select the option directly affecting or treating the client, which is antibiotics. Diagnostic tests do not treat the client. Content – Medical: Category of Health Alteration – Emergency: Integrated Nursing Process – Implementation: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level – Application: Concept – Perfusion. 5. 1. The client diagnosed with neurogenic shock will have dry, warm skin, rather than cool, moist skin as seen in hypovolemic shock. 2. The client will have bradycardia instead of tachycardia, which is seen in other forms of shock. 3. Wheezing is associated with anaphylactic shock. 4. Decreased bowel sounds occur in the hyperdynamic phase of septic shock. TEST-TAKING HINT: The test taker should identify the body system the question is addressing. In this case, neuro- indicates the question relates to the neurological system. With this information only, the test taker could possibly rule out option “4,” which refers to the gastrointestinal system, and option “3,” which refers to the respiratory system. Although bradycardia is in the cardiac system, the pulse rate is controlled by the brain. Content – Medical: Category of Health Alteration – Emergency: Integrated Nursing Process – Assessment: Client Needs – Physiological Integrity, Reduction of Risk Potential: Cognitive Level – Analysis: Concept – Perfusion. 6. 1. It is too late to ask the client about drug allergies because the medication has already been administered. 2. Obtaining a specimen after the antibiotic has been initiated will skew the culture and sensitivity results. It must be obtained before the antibiotic is started. 3. Anytime a nurse administers a medication for the first time, the client should be observed for a possible anaphylactic reaction, especially with antibiotics. 4. The client is being discharged and the nurse can encourage the client to do this at home, but it is not appropriate to do in the emergency department. TEST-TAKING HINT: The test taker must be observant of information in the stem. The nurse has already administered the medication, and checking for allergies after the fact will not affect the client’s outcome. This is a violation of the five (5) rights; this medication cannot be the right medication if the client is allergic to it. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level – Application: Concept – Medication. 7. 1. Ambulating the client in the hall will not address the etiology of the client’s chills and fever; in fact, this could increase the client’s discomfort. 2. Monitoring these laboratory data does not address the etiology of the client’s diagnosis. 3. Sequential compression devices help prevent deep vein thrombosis. 4. Antipyretic medication will help decrease the client’s fever, which directly addresses the etiology of the client’s nursing diagnosis. TEST-TAKING HINT: The test taker must know the problem “alteration in comfort” is addressed by the goal and the interventions address the etiology, which is “chills and fever.” Content – Medical: Integrated Nursing Process – Diagnosis: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level – Analysis: Concept – Perfusion. 8. 1. Specimens should be put into biohazard bags prior to leaving the client’s room. 2. This is the appropriate way to clean hands and does not warrant intervention. 3. This is the appropriate way to dispose of soiled linens and does not warrant intervention. 4. Taking a stethoscope from a client who is in isolation to another room is a violation of infection-control principles. TEST-TAKING HINT: This is an “except” question. The stem is asking which action warrants intervention; therefore, the test taker must select the option indicating an inappropriate action by the unlicensed assistive personnel. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level – Synthesis: Concept – Nursing Roles. 9. 1. Cardiogenic shock occurs when the heart’s ability to contract and pump blood is impaired and the supply of oxygen to the heart and tissues is inadequate, such as occurs in myocardial infarction or valvular damage. 2. These client’s signs/symptoms make the nurse suspect the client is losing blood, which leads to hypovolemic shock, which is the most common type of shock and is characterized by decreased intravascular volume. The client’s taking of NSAID medications puts her at risk for hemorrhage because NSAIDs inhibit prostaglandin production in the stomach, which increases the risk of developing ulcers, which can erode the stomach lining and lead to hemorrhaging. 3. In neurogenic shock, vasodilation occurs as a result of a loss of sympathetic tone. It can result from the depressant action of medication or lack of glucose. 4. Septic shock is a type of circulatory shock caused by widespread infection. TEST-TAKING HINT: The test taker must look at the signs and symptoms and realize this client is in shock. Tachycardia and hypotension with clammy skin indicate shock. The additional information in the stem describes a particular medication, an NSAID, which can cause a peptic ulcer. Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Physiological Integrity, Reduction of Risk Potential: Cognitive Level – Analysis: Concept – Perfusion. 10. 1. Monitoring the telemetry will not prevent cardiogenic shock. It might help identify changes in the hemodynamics of the heart, but it does not prevent anything from occurring. 2. Turning the client every two (2) hours will help prevent pressure ulcers, but it will do nothing to prevent cardiogenic shock. 3. Promoting adequate oxygenation of the heart muscle and decreasing the cardiac workload can prevent cardiogenic shock. 4. Placing the client’s head below the heart will not prevent cardiogenic shock. This position can be used when a client is in hypovolemic shock. TEST-TAKING HINT: If the test taker has no idea what the correct answer is, the test taker should apply Maslow’s hierarchy of needs, which states oxygenation